Healthcare Provider Details

I. General information

NPI: 1548786320
Provider Name (Legal Business Name): MELISSA JASMINE PENA LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2017
Last Update Date: 11/20/2023
Certification Date: 11/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 POPLAR AVE
MODESTO CA
95354
US

IV. Provider business mailing address

100 POPLAR AVE
MODESTO CA
95354-0510
US

V. Phone/Fax

Practice location:
  • Phone: 209-550-5869
  • Fax:
Mailing address:
  • Phone: 209-550-5869
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT142512
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: